Donation Form

* Required

Personal Details

Title

First Name *

Last Name *

Contact Details

Email Address for Receipt Purposes *

Mobile Phone Number/Home Phone Number *

Postal Address

I wish to give a donation

Donation Amount $100 $75 $50 $20 or enter an amount below

Payment Details

Cheque Credit Card Bank Transfer

Please make cheques payable to Multiple Sclerosis Auckland

We will contact you to take credit card details over the phone.

Deposited into MS Account, ASB Bank, St Lukes Branch,
Acc No. 12 3047 0088939 00

Please remember to put in following information;
(Particulars: "Donation", Code: Your Surname, Reference: Your First Name. )

Other Options

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